MEMBER NOTICE, APPEALS AND FAIR HEARINGS Sample Clauses

MEMBER NOTICE, APPEALS AND FAIR HEARINGS. 8.6.1 HMO must send Members the notice required by 1 Texas Administrative Code Section 357.5, whenever HMO takes an action to deny, delay, reduce or terminate covered services to a Member. The notice must be mailed to the Member no less than 10 days before HMO intends to take an action. If an emergency exists, or if the time within which the service must be provided makes giving 10 days notice impractical or impossible, notice must be provided by the most expedient means reasonably calculated to provide actual notice to the Member, including by phone, direct contact with the Member, or through the provider's office. 8.6.2 The notice must contain the following information: 8.6.2.1 Member's right to immediately access TDH's Fair Hearing process; 8.6.2.2 a statement of the action HMO will take; 8.6.2.3 the date the action will be taken; 8.6.2.4 an explanation of the reasons HMO will take the action; 8.6.2.5 a reference to the state and/or federal regulations which support HMO's action; 8.6.2.6 an address where written requests may be sent and a toll-free number Member can call to: request the assistance of a Member representative, or file a complaint, or request a Fair Hearing; 8.6.2.7 a procedure by which Member may appeal HMO's action through either HMO's complaint process or TDH's Fair Hearings process; 8.6.2.8 an explanation that Members may represent themselves, or be represented by HMO's representative, a friend, a relative, legal counsel or another spokesperson; 8.6.2.9 an explanation of whether, and under what circumstances, services may be continued if a complaint is filed or a Fair Hearing requested; 8.6.2.10 a statement that if the Member wants a TDH Fair Hearing on the action, Member must make the request for a Fair Hearing within 90 days of the date on the notice or the right to request a hearing is waived; 8.6.2.11 a statement explaining that HMO must make its decision within 30 days from the date the complaint is received by HMO; and 8.6.2.12 a statement explaining that a final decision must be made by TDH within 90 days from the date a Fair Hearing is requested.
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Related to MEMBER NOTICE, APPEALS AND FAIR HEARINGS

  • Complaints and Appeals As a Premera member, you have the right to offer your ideas, ask questions, voice complaints and request a formal appeal to reconsider decisions we have made. Our goal is to listen to your concerns and improve our service to you. If you need an interpreter to help with oral translation, please call us. Customer Service will be able to guide you through the service. We would like to hear from you. If you have an idea, suggestion, or opinion, please let us know. You can contact us at the addresses and telephone numbers found on the back cover. Please call us when you have questions about a benefit or coverage decision, our services, or the quality or availability of a healthcare service. We can quickly and informally correct errors, clarify benefits, or take steps to improve our service. We suggest that you call your provider of care when you have questions about the healthcare they provide.

  • Grievance and Appeals Unit See Section 9 for contact information. You may also contact the Office of the Health Insurance Commissioner’s Consumer Resource Program, RIREACH at 1-855-747-3224 about questions or concerns you may have. A complaint is an expression of dissatisfaction with any aspect of our operation or the quality of care you received from a healthcare provider. A complaint is not an appeal. For information about submitting an appeal, please see the Reconsiderations and Appeals section below. We encourage you to discuss any concerns or issues you may have about any aspect of your medical treatment with the healthcare provider that furnished the care. In most cases, issues can be more easily resolved if they are raised when they occur. However, if you remain dissatisfied or prefer not to take up the issue with your provider, you can call our Customer Service Department for further assistance. You may also call our Customer Service Department if you are dissatisfied with any aspect of our operation. If the concern or issue is not resolved to your satisfaction, you may file a verbal or written complaint with our Grievance and Appeals Unit. We will acknowledge receipt of your complaint or administrative appeal within ten (10) business days. The Grievance and Appeals Unit will conduct a thorough review of your complaint and respond within thirty (30) calendar days of the date it was received. The determination letter will provide you with the rationale for our response as well as information on any possible next steps available to you. When filing a complaint, please provide the following information: • your name, address, member ID number; • the date of the incident or service; • summary of the issue; • any previous contact with BCBSRI concerning the issue; • a brief description of the relief or solution you are seeking; and • additional information such as referral forms, claims, or any other documentation that you would like us to review. Please send all information to the address listed on the Contact Information section.

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  • Administrative Appeals An administrative appeal is a request for us to reconsider a full or partial denial of payment for covered healthcare services for the following reasons: • the services were excluded from coverage; • we determined that you were not eligible for coverage; • you or your provider did not follow BCBSRI’s requirements; or • a limitation on an otherwise covered benefit exists. You are not required to file a complaint (as described above), before filing an administrative appeal. If you call our Customer Service Department, a Customer Service Representative will try to resolve your concern. If the issue is not resolved to your satisfaction, you may file a verbal or written administrative appeal with our Grievance and Appeals Unit. If you request an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of payment for covered healthcare services. The Grievance and Appeals Unit will conduct a thorough review of your administrative appeal and respond within: • thirty (30) calendar days for a prospective review; and • sixty (60) calendar days for a retrospective review. The letter will provide you with information regarding our determination.

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